Abstract

To evaluate the performance of this institution in its delivery of care to elderly patients with a hip fracture over an 11-year period and to establish recommendations to improve practice.

Regular prospective audits of a cohort of 50 patients have been undertaken between 1990 and 2000. A larger and more comprehensive retrospective audit of 100 patients was performed in 2001. Goals were set regarding time to admission, time to surgery and to discharge in close accordance with the best practice guidelines devised by the Royal College of Physicians in 1989.

There has been an alarming decline in standards in key areas.

Time from A& E to admission: at best 78% of patients within 3 hours, 4% in 2001.

Current practice is less than ideal. Clinical governance involves a dual responsibility – of the clinician to maintain high standards and of the management to provide adequate resources. Both need addressing to reverse the current trend.

Introduction: This paper reports leg alignment and knee surface measurements taken from 100 young adult limbs using actual physical bone measurements (APB).

Method: The specimens were part of the Spitalfields Collection of 1000 skeletons held in the Natural History Museum, London. Selection criteria included full life documentation, absence of degenerative change and perfect preservation. There were 28 females (45 knees) and 29 males (55 knees). Mean age was 40 years. The femora and tibiae were accurately articulated with the knee extended. Digital images were obtained in neutral, 15 degrees internal rotation and 15 degrees external rotation.

Results: Mean axial alignment of both sexes was valgus (female> male). Using the 2 tailed t-test valgus alignment differed significantly from neutral alignment (p< 0.001) in this population. Internal rotation exaggerated an alignment into valgus and external rotation exaggerated an alignment into varus. The knee joint inclination of both sexes was valgus with respect to the mechanical axis of the tibia (female> male). The physiological valgus angle of the knee more closely resembled the accepted value of 6 degrees in the female.

Discussion: This is the first report of APB measurements as opposed to x-ray analysis in a normal population. It is clear that considerable individual variation occurs in all parameters. Development is likely to be affected by genetic, cultural and occupational factors. Measurements are also affected by limb rotation. We believe that arthroplasty techniques may be more successful if alignment is planned to the individual.

Introduction Dynesys flexible stabilisation was developed by Giles Dubois in 1992, and first used in 1994 (1). Our unit has undertaken 375 operations to date. We report a consecutive series of 200 patients who underwent Dynesys flexible stabilisation in the management of intractable lower back pain.

Methods Access to our spinal service is exclusively from a back assessment centre run by a triaging nurse practitioner who works closely with the senior author. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. Patients were only accepted for the study if exhaustive conservative management had failed. They underwent operation by the senior author between September 2000 and March 2003. Patients were divided into two groups: Group 1 – Cases where implantation was used as an adjunct to other procedures including decompression, discectomy, or posterior lumbar interbody fusion. (32 male, 36 female, Mean age 56years (range 31–85)) Group 2 – Patients with back pain and/or sciatica in which no other procedure was used. (65 male 67 female, Mean age 58years (range 27–86)) All patients were profiled prospectively using the Oswestry Disability Index (ODI), SF36 and Visual Analogue Scale (VAS). Patients were reviewed post-operatively using the same measures at 3, 6 and 12 months, and yearly thereafter. Follow-up was 95% at 2 to 5 years.

Results Group 1 – Mean ODI fell from 54 pre-op to 24 at four years. Mean SF36 improved from 43 pre-op to 56 at four years Group 2 – Mean ODI fell from 49 pre-op to 28 at four years. Mean SF36 improved from 40 pre-op to 62 at four years. Similar trends were observed in both groups at five years with these favourable scores tending back towards pre-operative levels. Screw failures, either loosening or fracture, occurred at a rate of 15% over the follow-up period.

Discussion Our results support the use of flexible stabilisation as an alternative to spinal fusion. There is currently no consensus on absolute indications for the procedure however. Such indications can only be defined following clinical outcome. Perceived indications were based on contemporary understanding of the biomechanical effects of the construct. Further investigation of these variables is clearly desirable. Screw failures (15%) have detracted from the overall success, although the relationship between such failures and poor outcomes is complex and difficult to elucidate at the current time. The virtue of flexible stabilisation over fusion includes avoidance of domino effect, reversibility and possible healing of a painful segment. The key issue is whether flexible stabilisation is as effective and this requires prospective randomised controlled investigation, both against fusion, and against conservative management. We feel our results in this difficult group of patients are reasonable and continue to use it in our practice.

We report a consecutive series of 352 patients with back pain treated by Dynesys flexible stabilisation between July 2000 and November 2004, to include perceived indications, surgical techniques and complications. A detailed analysis of the first 120 cases with minimum follow up of 2 years is included. Our unit has undertaken 352 operations to date, and this communication reports all cases. Follow up is to 48 months.

All patients were profiled prospectively using the Oswestry Disability Index, Euroquol, SF36, Pain analogue scale, Pain chart and modified Zung. The same measuring instruments were used at review for which follow up was 100%

The procedure involves paired bilateral pedicle screw instrumentation above and below the level of perceived pathology, with each screw pair connected by load relieving carbopolyurethane flexible spacers, in conjunction with a tension band polyethylene cord passed through the spacer. This construct is then held under tension with screws in the main pedicle screws.

All patients are profiled at entry to the hospital service using a proforma which includes the measures outlined above. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. All our cases have failed conservative treatment before enrolling for surgery.

There was significant improvement in symptoms for most of the patients in the series. However clear patterns emerged as to those cases in which Dynesys is contra-indicated.

This is the largest series of cases reviewed so far in the literature.

Introduction We report the clinical and radiographic outcome of a consecutive series of 138 hydroxyapatite coated total knee replacements with a mean follow up of 11 years (10–13 years)

Method and Results These patients were entered into a prospective study. There were 74 females and 32 males. Indications for surgery were osteoarthritis in 131 knees, rheumatoid arthritis in 5 knees and pigmented villo-nodular synovitis in 2 knees. The mean age of the patient was 72.5 years at the time of surgery. All living patients (76 knees) were examined and X rayed. A current Hospital for Special Surgery knee score (mean 83 points) was obtained for comparison with the preoperative profile (mean 55 points).The knee status of deceased patients was known within the year of death. No patient was lost to follow up. Radiological evaluation, assessed according to the method described by the Knee Society, revealed no loosening in surviving patients, and there are no impending revisions. Seven prostheses have been revised, giving a cumulative survival rate of 93 percent at 13 years.

Discussion. We believe this to be the longest follow up report available for an hydroxyapatite coated knee replacement, and the first using the Insall Burstein knee. Results can thus be compared with the identical prosthesis using cemented fixation. Further modifications would be likely to improve reliability.

Introduction: We report a series of 90 patients enrolled in a prospective study of Dynesys stabilisation reviewed at 12 to 30 months.

The procedure involves, at each segment, cephalad and caudad pedicle screws connected with a polycarbourethane spacer and polyethylene cord. It achieves load relief and controlled flexion. Since 1996, 7000 procedures have been undertaken globally.

Method: Indications are analogous to consideration for fusion. Entry criteria included 1) Unresolved and unacceptable lumbar back pain despite protracted conservative management and 2) Definite pathology where symptoms could be abolished by anaesthetising the target segments.

Where root compression was present, a midline approach and posterior screw placement was used in conjunction with open decompression. With back pain alone a bilateral Wiltse approach and posterolateral placement was used.

All patients were assessed pre and post surgery with SF36, Oswestry Disability Index and pain analogue scores and modified Zung. Standing radiographs were obtained post surgery and at review. Follow up was at 6, 12, 24 and 52 weeks in addition to this review.

Results: Follow up was 100%. 89 patients survived. Mobilisation was achieved on day 1 and discharge usually by day 2.Based on the above outcome measures and patient satisfaction good to excellent results were achieved in 74%(66/89). Screw loosening or breakage occurred in 8%, and was associated with a poor result.

Discussion: Dynesys flexible stabilisation offers a simple alternative to fusion with less potential for adjacent ‘Domino’ failure. It differs from tension ligament systems such as Graf. At this stage the results appear at least as good as a comparable cohort of fusion patients.

The present series is early, but gives grounds for encouragement. Screw loosening and failure are technical problems detracting from the result and require further development.

We are continuing to use the technique.

Introduction: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used.

Method: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics.

Discussion: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation.

INTRODUCTION: We report a series of 90 patients enrolled in a prospective study of Dynesys stabilisation reviewed at 12 to 30 months.

The procedure involves, at each segment, cephalad and caudad pedicle screws connected with a polycarbo-urethane spacer and polyethylene cord. It achieves load relief and controlled flexion. Since 1996, 7000 procedures have been undertaken globally.

METHOD: Indications are analogous to consideration for fusion. Entry criteria included (1) unresolved and unacceptable lumbar back pain despite protracted conservative management and (2) definite pathology where symptoms could be abolished by anaesthetising the target segments.

Where root compression was present, a midline approach and posterior screw placement was used in conjunction with open decompression. With back pain alone a bilateral Wiltse approach and posterolateral placement was used.

All patients were assessed pre- and post-surgery with SF36, Oswestry Disability Index and pain analogue scores and Modified Zung. Standing radiographs were obtained post- surgery and at review. Follow-up was at six, 12, 24 and 52 weeks in addition to this review.

RESULTS: Follow-up was 100%. 89 patients survived. Mobilisation was achieved on day 1 and discharge usually by day 2. Based on the above outcome measures and patient satisfaction good to excellent results were achieved in 74% (66/89). Screw loosening or breakage occurred in 8%, and was associated with a poor result.

DISCUSSION: Dynesys flexible stabilisation offers a simple alternative to fusion with less potential for adjacent ‘Domino’ failure. It differs from tension ligament systems such as Graf. At this stage the results appear at least as good as a comparable cohort of fusion patients.

The present series is early, but gives grounds for encouragement. Screw loosening and failure are technical problems detracting from the result and require further development.

We are continuing to use the technique.

INTRODUCTION: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used.

METHOD: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics.

DISCUSSION: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation.